CREMATION ACT 1929
Cremation Regulations 1954
Form 7 (Reg. 12)
Certificate of Medical Practitioner
Deceased/ Name:
Address:
Date of birth: / / Age:
Marital status: Male Female Unspecified
Occupation:
Doctor
/ Name:
Address:
Are you a spouse, de facto partner or relative of the deceased?
No
Yes. Nature of relationship:
As far as you are aware, do you have a pecuniary interest in the deceased’s estate or any other pecuniary interest in the deceased’s death?
No
Yes. Give details:
Were you the deceased’s usual doctor? No Yes
Recent care of deceased /
During the 4 weeks prior to death did the deceased receive medical or nursing care?
No
Yes. Where was the deceased cared for?
Hospital
Nursing home
Home
Other
If cared for at home or other place, who provided care?
Professional health care providers
Relatives, friends, others
Give names and relationship to the deceased: ______
Did you attend the deceased during his or her last illness?
No Yes Since what date? / /20__
Did any other doctor(s) attend the deceased during his or her last illness?
No
Yes. Give names: ______
Last illness / Brief clinical history of last illness including diagnoses and events leading to death.
Details of death / Date / /20__ Time a.m./p.m.
Place where the deceased died:
Home
Address ______
Hospital
Address ______
Other
Address ______
CREMATION ACT 1929
Cremation Regulations 1954
Form 7 (Reg. 12)
Certificate of Medical Practitioner
Details of death (cont’d) / Were you present when the deceased died?Yes
No. When did you last see the deceased alive?
Date / /20__ Time a.m./p.m.
Did you examine the deceased’s body after death?
No
Yes. Give details: ______
Do you have any reason to suppose that a further examination of the deceased’s remains may be desirable?
No
Yes. Give details: ______
Cause of death
(* If a Medical Certificate
of Cause of Death is
attached, answers are
not required to these
questions.)
/ Was a post mortem performed?
No
Yes. Give details of results: ______
*Did you sign the Medical Certificate of Cause of Death?
Yes
No. Name of the doctor who signed the certificate: ______
*Direct cause of death:
*Antecedent causes of death (if any):
*Conditions contributing to or accelerating death (if any):
Clinical observations / Do you know, or have reason to suspect, that the deceased’s death was directly or indirectly due toany of the following? (tick or circle if yes)
violence poison
privation or neglect medical procedure
drowning suffocation
burns
In view of the deceased’s lifestyle and health, do you have any doubts about the character of thedeceased’s illness or cause of death?
No
Yes. Give details: ______
Safety of cremation / At the time of death was the deceased fitted with a cardiac pacemaker, defibrillator or other battery operated implant or device? Yes No/unknown
(If yes, has it been removed? Yes/No)
Had the deceased received any of the following radioactive treatments?
Palliation for bone metastases:
• Strontium-89 injection during the 12 months prior to death No Yes*
• Radium-223 injection during the 2 months prior to death No Yes*
• Samarium-153 injection during the 3 weeks prior to death No Yes*
• Rhenium-188 injection during the week prior to death No Yes*
Infusion for liver cancer or metastases:
•Yttrium-90 or Rhenium-188 during the 2 weeks prior to death No Yes*
Therapy for thyroid cancer, endocrine tumours, or non-Hodgkin’s lymphoma:
•Iodine-131 (injection or oral) during the week prior to death No Yes*
Radioactive implant (permanent), e.g. for prostate cancer No Yes*
•Iodine-125 seed implant during the 12 months prior to death
* If yes — contact the Radiation Safety Officer/Physicist at the treating institution for provision of required information to the crematorium.
Are you aware of anything else that could render cremation unsafe?
No
Yes. Give details: ______
Certification of medical
practitioner / I certify that the information set out above is true and correct and that I have not omitted any relevant information.
Signature Date / /20__